Incident investigation·December 27, 2024

On 12/27/2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 8:30 AM to conduct a Case Management visit for the purpose of following up on a self-reported incident and met with Jessi Kaur, Memory Care Director and Alberto Golia, Executive Director. LPA was informed that on 12/19/2024, R1 had wandered out of the facility unassisted. R1 was found several minutes after staff were aware of their absence and located R1 approximately 1 block away with no signs of injury or change of condition. Upon file review, R1 is not able to the facility unassisted. The facility is aware of R1's wandering behavior and did an elopement drills with all staff on all shifts on 12/19/2024. Furthermore, the facility has taken additional steps to ensure more individualized activities to keep R1 engaged. LPA found that facility is taking appropriate preventative measures to ensure R1 is provided individualized updates on supervision. Lastly, the facility is ensuring all residents are properly supervised and engaged moving forward. Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. An exit interview was conducted. This report was reviewed with Alberto Golia, Executive Director and a copy of the report along with Appeal Rights left at the facility.